COLUMBIA — With the federal government waiting for an answer and a deadline only four months away, Missouri has yet to commit to a plan for creating a health insurance exchange.

The creation of a health insurance exchange is part of the Affordable Care Act, which the U.S. Supreme Court ruled to uphold late last month.

States have until Nov. 16 to tell the federal government whether they will implement a state-based exchange. If Missouri chooses to run its own exchange, it will have until Jan. 1 to create one that is approved by the U.S. Department of Health and Human Services.

The deadlines are in place so the federal government can evaluate states' plans in time for enrollment in the exchanges, which begins in late 2013. If a state decides not to run its own exchange or fails to meet federal requirements, the federal government would step in and run the exchange starting in January 2014.

Missouri's Republican-controlled General Assembly maintains strong opposition to the health care law and interference from the federal government, but the state has yet to adopt a plan for its own exchange program. Instead, Republican leadership has opted to wait for the outcome of the November general election.

House Majority Leader Tim Jones, R-Eureka, told The Associated Press that if Republican Mitt Romney succeeds in his bid for the presidency, he thinks Romney would suspend the exchange requirement.

The exchange

Health care exchanges are intended to establish online marketplaces that allow people and small businesses to shop for insurance plans and buy health insurance with the aid of federal subsidies and tax credits.

The Affordable Care Act requires the exchange website to present information on health plans, rates and benefit options in a standardized format as well as provide additional points of entry, such as toll-free telephone lines.

As of June 5, 10 states and the District of Columbia had enacted legislation to setup state-based exchanges, according to the National Conference of State Legislatures. Two states, Utah and Massachusetts, established their own exchanges before the federal health care law passed in March 2010.

Of the remaining states, three created exchanges by executive order, seven have pending legislation, and 28 have either not taken action or been unable to pass legislation to set up an exchange.

Missouri, as well as six of its neighboring states, falls into this last category.

States have three options for creating and running a health insurance exchange: 1) an entirely state-based operation, 2) a partnership with the federal government or other states or 3) an entirely federally run exchange.

If states choose to implement their own exchanges, they can be run through either an existing government agency or by an independent authority.

The ballot initiative

Missouri's voters will have a chance to provide their input on the future of an exchange in the state during the general election.

During the 2012 legislative session, state lawmakers approved a measure for the Nov. 6 ballot. The initiative asks voters whether state officials should be prohibited from establishing a health insurance exchange without prior voter or legislative approval. If approved by voters, the initiative also would prohibit state departments from using federal money to set up the online marketplace.

No matter how Missouri residents vote on the ballot, however, the state will still be required to create either a state-based exchange or a rely on the federal government for one.

Missouri's Lt. Gov. Peter Kinder recently filed a lawsuit against the initiative's ballot summary, which was submitted by the secretary of state's office.

The ballot summary now states:

“Shall Missouri law be amended to deny individuals, families, and small businesses the ability to access affordable health care plans through a state-based health benefit exchange unless authorized by statute, initiative or referendum or through an exchange operated by the federal government as required by the federal health care act?”

While Kinder called the summary "biased" and misleading, the secretary of state's office has stood by the language.

Missouri residents voted overwhelmingly in 2010 to block implementation of the federal health care law by approving Proposition C by more than 70 percent, a point Republicans have continuously used while campaigning against the law. Proposition C was specifically targeted at blocking the mandate for people to buy health insurance and the punishment of those who do not. The U.S. Supreme Court, however, upheld both parts of the law.

Missouri's progress and past actions

So far, Missouri has made little progress toward an exchange, despite some initial federal grants and state legislation.

The Missouri Department of Insurance received a $1 million federal planning grant for an exchange in September 2010. In August 2011, the Missouri Health Insurance Pool, a nonprofit insurer associated with state government, received a $20.8 million federal grant to update Missouri's computer systems in preparation for the exchange.

State officials spent the planning grant and $1.3 million of the other grant, but work on planning for and creating an exchange came to a halt after opposition emerged in the legislature. Republican lawmakers said the money would be used for more than just updating the state's computer systems and that they would help build the basis for the federal health care law.

During the 2012 legislative session, lawmakers rejected another federal grant, this one for $50 million. It would have been used to upgrade Missouri's Medicaid Information Technology system.

Democratic Gov. Jay Nixon has said he would not use an executive order to create an exchange — an action some lawmakers had accused him of trying to use previously — and that Missouri would wait until after the U.S. Supreme Court's ruling before working on an exchange.

Debate over the health care exchange is taking place in the run-up to the Nov. 6 election. Here's what candidates for local legislative seats had to say about the issue:

Senate District 19:

"I don't think anyone knows the answer to that," incumbent Sen. Kurt Schaefer (R) said when asked whether Missouri should run its own exchange. He said a public debate is necessary. Schaefer also said the federal government should extend the deadlines for implementing an exchange given confusion about how states should run them.

Rep. Mary Still (D) said the exchange is a portal that would "bring transparency and competition into the marketplace." Still also said it would be better to have a state-based exchange and that "the best thing for us to do is to move forward and be ready (for the deadlines)."

House District 44:

Caleb Rowden (R) said he is still forming an opinion on whether an exchange is good for Missouri because there are constantly new variables and "so much instability that it is causing all the state to have to step back and look at what is best for the state." Rowden added that if Missouri has to implement an exchange, then it should be state-based because "local lawmakers know better about what is going on in the state than the federal government."

Ken Jacob (D) said he doesn't know why Missouri would say no to implementing the exchange. He added that Republicans are putting "partisanship before plain and simple good business."

House District 45:

Incumbent Rep. Chris Kelly (D) said Missouri should create its own state-based exchange. Although he said he supports the health care law, he thinks the federal government is too "intrusive and over regulative."

House District 46:

"No. No exchange at all," Fred Berry (R) said, adding that Missouri must block the exchange to stop implementation of the Affordable Care Act. "The problem with the exchange is that if the state accepts the exchange, it tacitly accepts the (law)."

Incumbent Rep. Stephen Webber (D) said the legislature should have set up an exchange last year. "For folks worrying about states' rights, it seems like the logical thing to do." He added that the state could create an exchange with more flexibility than the federal model.

House District 47:

Mitch Richards (R) said he would need to study the issue more but he is "generally against" the exchange and "skeptical" of the promise of funding from the federal government.

John Wright (D) could not be reached for comment, but at a July 12 forum he said his opinion of the health care law "doesn't much matter" because of the Supreme Court ruling. Wright also said it was to "let the law take shape and deal with problems at the federal level."

House District 50

Incumbent Rep. Caleb Jones (R) said "we pretty much have to" implement an exchange because it is required under the federal health care law. He added that Missouri should have a state-based exchange because it would be more efficient. "Anytime there is a federal requirement ... the first thing we need to do is make sure we are the ones doing it."